Patient history pt.1 Flashcards
What should a diagnosis be based on?
80% of diagnoses should be
made on history alone, with the signs you elicit adding an extra 10% and tests only
giving the final 5% or so
Things that should be done before and during taking patient history
- Try to be in a setting that offers privacy and comfort for the patient (bed availability too would be a plus)
- Establish the patient’s name and check their date of birth
- Introduce yourself and begin with open-ended questions
- Let them tell their story, but if they stray off topic, gently steer them back towards the points
- Be conversational rather than interrogative
What are the main points that should be adressed when taking a history?
- Presenting complaint
- History of presenting complain
- Risk factors
- Past medical history
- Drug history
- Family history
- Social history
- System review
- Summarizing
Open ended questions examples
- Tell me more about your …
- Why have you come to see me today?
- How can I help you?
- What brought you in to the hospital/clinic today?
- What seems to be the problem?
Presenting complaints key takeaways
- Figuring out why the patient has come to the hospital/clinical
- Write their main problems in the words they used instread of medical terms and who reffered them (if the referral letter has a different presenting complaint
then document this too.)
History of presenting complaints tips
- Ask questions aimed at differentiating the causes of
the presenting complaint (Direct/Specific or ‘closed’ questions about the differential diagnoses you have in mind - Try to exclude potentially life-threatening causes first
- Use the SOCRATES questions for complaint
Questions to be asked for history of presenting complaint?
- When did it start?
- What was the first thing you noticed?
- Progress since then
- SOCRATES
SOCRATES stands for
- Site
- Onset (gradual, sudden)
- Character
- Radiation
- Associations (e.g. nausea, sweating)
- Timing of pain/duration
- Exacerbating and alleviating factors
- Severity (e.g. scale of 1-10)
What should be done for risk factor section of history
Document recognized risk factors for important differentials
What should be included in the past medical history section of history taking
- Ask about previous medical problems/operations and attempt to gauge the severity of each (eg hospital/ICU admissions, exercise tolerance (ET), treatment)
- Previous episodes and investigations/treatments
- Ask specifically about MIJTHREADS.
MIJTHREADS stands for
MI, jaundice, TB, high BP, rheumatic fever, epilepsy, asthma, diabetes, stroke
What should be included in the drug history section of history taking
- Document all drugs along with doses (including OTC medication, herbal supplements, oral contraceptives), times taken, and any recent changes
- Always document drug allergies along with the reaction precipitated (e.g. nausea, diarrhea, rash, wheeze, full blown anaphylaxix), or no known drug allergies (NKDA)
- Ask about compliance too
What should be included in the social history section of history taking?
- Job
- Marital status
- Spouse’s job and heatlh
- Home: Ask about who they live with, the kind of house (eg bungalow, residential home), any home help, any stairs at home, who visits
- Mobility: Walking aids (stick/frame), exercise tolerance (how
far can they walk on level ground? Can they climb stairs?); own ADLs (cooking, dressing, washing) - Lifestyle: alcohol (units/wk), smoking (cigarettes/d and pack-years), recreational drugs, when did the use start or how long has it been until they quit
- What can the patient not do because of the illness
How are pack years calculated?
Smoking: 20 cigarettes/d for 1yr = 1 pack-year
How is alcohol consumption calculated?
Alcohol: 1 unit = ⅓ pint of beer (1/2 of a beer), ½ glass of wine, 1 measure of spirits
